Use of fast-growing caesareans

According to experts, the use of caesareans to deliver babies has reached epidemic proportions, with the procedure developing at an alarming rate.
While caesareans can be a critical intervention for the safety of the mother and child, for example if the baby is in distress or her mother is bleeding before birth, experts estimate that the procedure would be about 10 to 15% births. used when medically necessary.
But in a new series of studies and commentaries published in the Lancet, a team of researchers found that in many countries, the number of cesarean sections is increasing rapidly, accounting for more than 21% of all births worldwide. 2015, compared to just over 12% at the present time. turning of the millennium.
In the United Kingdom, the figure is just over 26%, but in some countries more than half of births involve the procedure: in the Dominican Republic, more than 58% of babies are born in this way, while In Egypt, this figure is 63%. just at birth in an institutional setting.
Experts say more needs to be done to educate women, their families, and health professionals about the potential risks of cesareans when they are not needed for medical reasons.
"For the mother, for her future pregnancy, the risk of premature birth, rupture of the uterus and placenta in the wrong part of the uterus is increased, which means that". she runs the risk of postpartum hemorrhage and requires a hysterectomy, "said Jane Sandall. , professor of social sciences and women's health at King's College London and co-author of one of the studies.
Some of the risks increase the number of caesarean sections in a woman: according to a study mentioned by the team, the need for a hysterectomy has increased from one in 25,000 pregnancies in women who have never had cesarean to one in twenty who had three or more.
The authors add that there is also a risk of blood clots forming in the mother's legs, problems of anesthesia and infection in people opting for a caesarean section, while in the baby , the risk of problems related to the development of the immune system is higher. autoimmune disorders. The procedure also affects the composition of the baby's intestinal microbiome and increases his risk of obesity and asthma.
The authors note that the risks are generally low and depend on where the operation takes place. They also admit that little research has been done on the psychological effects of Caesarean section in relation to natural childbirth.
Sandall said there was no purpose or goal, but it was important to listen to why women chose to have this procedure.
"For many women, it's the fear of birth or something that happened to her when she was treated. She was treated in a way that did not please her and where she uses [a caesarean] as a way to regain control, "she said.
Sandall said that time constraints and staffing issues meant that women were not always getting the support they needed, but that doctors should provide information and suggest ways to alleviate the fears surrounding natural birth.
"It's our job to provide as accurate information as possible. It's not up to us to tell women what to do, "she added.
The new study suggests that the global increase in the number of Caesareans is attributable to more women giving birth in medical facilities such as hospitals, as well as increased use of procedures in these centers.
More specifically, the reports suggest that factors that may play a role include the fear of women suffering from labor and the idea that a caesarean section is safer. For obstetricians, the fear of being prosecuted – which is more likely for natural deliveries – a greater financial reward, or even a shift in work schedules, could mean that they are more likely to be delayed. accept or suggest a request for intervention.
"In many contexts, young obstetricians have become experts in [caesarean sections]but lose confidence in assisted natural deliveries and deliveries by breech, "warn experts.
Although research is lacking to find the best way to combat the overuse of caesareans, experts recommend better support for women and audits of the use of caesarean section, and stress the importance of midwives .
The team adds that while the proportion of caesareans is globally excessive, the use of the procedure varies from one country to another, with greater use in richer regions. By contrast, in 47 of the 169 countries studied by researchers, the rate of use of caesarean section is lower than is considered medically necessary: ​​in West and Central Africa, this figure is slightly higher at 4%, suggesting that some women and some babies lack life-saving equipment. care.
Caesareans are also more common in some countries among wealthier women and in the private sector.
Mandy Forrester, of the Royal College of Midwives, said it was "essential that women be aware of the possible complications of a short and long term caesarean section. For this to happen, we need to give midwives time to sit down and discuss the options available to the woman for the birth of her baby. It is very important that women make their decisions based on the best evidence available. "
"In Brazil, it is thought that normal childbirth is something the poor do."
In Brazil, more than half of births take place by caesarean section, according to the latest Lancet data. Although natural births are more common in public hospitals than in private clinics, about 55% of Brazilian women deliver by caesarean section.
"It's quite disturbing," said Silvana Granada, one of the leading reproductive researchers at the Brazilian Oswaldo Cruz Foundation (Fiocruz). According to Grenada, no less than 70% of women say they want a natural birth first. But this "turns upside down" as they reach the end of their pregnancy, the majority expressing their preference for caesareans.
Grenada said that a national study conducted by Fiocruz in 2012 had revealed that women often made this choice for fear of pain or because they thought that cesarean deliveries were safer. Until very recently, medical work practices in Brazil have done little to change this belief.
Until ten years ago, episiotomies – surgical cuts made during delivery – were used for every natural birth. The procedure is much less common now.
Other known practices for increasing pain are still common among deliveries, such as the use of the drug oxytocin, which can speed up work but is also known to increase discomfort. The study also revealed that doctors still often required women to stay in bed and forbid them to walk around or leave them without food or drink during work.
Another factor is the division between public and private maternities, where practices can be very different. Women of lower social status were more likely to give birth in a public unit, and sickness insurance schemes used in private maternity clinics often covered only cesarean deliveries. Grenada said that women who want a natural birth in a private clinic "are charged extra fees or have to pay the full cost of birth".
César Eduardo Fernandes, president of the Brazilian Federation of Gynecology and Obstetrics Associations, said that social and cultural factors also influenced women's choices regarding natural birth versus caesareans.
"In Brazil, it is thought that natural childbirth is something the poor do," he said. "Those with economic ability choose caesareans."
In private clinics, which often assign each patient a doctor to accompany her throughout pregnancy, the convenience of a caesarean birth of one hour compared to a long natural labor might also influence practices. Grenada said the majority of Caesarean sections in Brazil are scheduled in advance rather than when a woman gives birth, and are normally scheduled to take place during working hours during the week.
Legal risks for obstetricians are also a factor, according to Fernandes. "Obstetricians are the most pursued doctors in our country, after plastic surgeons," he said.
Brazil is taking action to combat its high rate of caesarean section. In July 2016, the federal government passed a resolution that caesareans should only be planned for high-risk pregnancies, and only after the 39th week. Data still needs to be collected to show the effect of this on cesarean rates in Brazil, but researchers and practitioners believe that they are declining.
Fiocruz's most recent studies, whose results were collected in 2016 and are still being analyzed, show an improvement over previous childbirth practices. Grenada stated that the number of births by caesarean section had decreased.
"It's better," she said. "But we still have a lot of work to do to get better deliveries, where the woman is the protagonist rather than the health care provider." – Guardian News and Media